Clinical Pearls

It is difficult to reliably distinguish clinically between typical and atypical causes of pneumonia. Therefore, diagnosis and empiric treatment of pneumonia are based upon the setting in which it was acquired (community acquired or nosocomial) and the immune status of the host. Clinical criteria, such as patient age > 50 years, coexisting illnesses, tachycardia, and tachypnea, can be used to risk stratify patients with pneumonia to decide who can be treated as an outpatient and who requires...

Definitions

Chronic bronchitis Clinical diagnosis characterized by excessive secretion of bronchial mucus and productive cough for 3 months or more in at least 2 consecutive years in the absence of any other disease that might account for this symptom. Chronic obstructive pulmonary disease (COPD) Disease state characterized by the presence of airflow obstruction caused by chronic bronchitis or emphysema. The airflow obstruction usually is progressive, may be accompanied by airway hyperreactivity, and may...

Answers To Case 6 Aortic Dissection Marfan Syndrome

Summary A 42-year-old man is brought in to the emergency room with severe chest pain, which was unrelieved by nitroglycerin. His blood pressure is elevated but asymmetric in his arms, and he has a new murmur of aortic insufficiency. The chest x-ray shows a widened mediastinum. All of these features strongly suggest aortic dissection as the cause of his pain. He is tall with pectus excavatum and other features of Marfan syndrome, which may be the underlying cause of his dissection. Most likely...

Answers

Reactivation tuberculosis (in this case, likely triggered by infliximab) usually involves the apical aspects of the lungs. 31.2 B. Pyridoxine (vitamin Bf)) is important for preventing the peripheral neuropathy that can complicate isoniazid therapy. If the numbness were caused by Pott disease, he should have back pain and other neurologic findings, such as lower-extremity weakness. 31.3 A. Because this woman is a household contact of a patient with active TB, she is among the highest...

Answers To Case 16 Ulcerative Colitis

Summary A young man comes in with a moderate to severe presentation of colitis, as manifested by crampy abdominal pain with tenesmus, low-volume bloody mucoid stool, and colonic dilatation on x-ray. He has no travel or exposure history to suggest infection. He reports a history of previous similar episodes, which suggests a chronic inflammatory rather than acute infectious process. What is the most likely diagnosis Colitis, probably ulcerative colitis. What is your next step Admit to the...

Answers To Case 45 Pleural Effusion Parapneumonic

Summary A previously healthy young woman comes in with a clinical diagnosis of community-acquired pneumonia that has not improved with outpatient treatment. She has diminished breath sounds and dullness to percussion on the left side of her chest, suggesting a large left-sided pleural effusion, which is confirmed by chest radiography. The effusion likely is caused by infection in the adjacent lung parenchyma and may be the cause of her failure to improve on antibiotics. Most likely diagnosis...

Approach To Health Maintenance Definitions

Cost-effectiveness Comparison of resources expended (dollars) in an intervention versus the benefit, which may be measured in life-years or quality-adjusted life-years. Primary prevention Identifying and modifying risk factors in subjects who have never had the disease of concern. Screening test Device used to identify asymptomatic disease in the hope that early detection will lead to an improved outcome. An optimal screening test has high sensitivity and specificity, is inexpensive, and is...

Approach To Sickle Cell Anemia Pathophysiology

The molecular structure of a normal hemoglobin molecule consists of two alpha-globin chains and two beta-globin chains. Sickle cell anemia is an autosomal recessive disorder resulting from a substitution of valine for glutamine in the sixth amino acid position of the beta-globin chain. This substitution results in an alteration of the quaternary structure of the hemoglobin molecule. Individuals in whom only half of their beta chains are affected are heterozygous. a stale referred to as sickle...

Comprehension Questions

34.1 Which of the following can be useful in the diagnosis of occult pulmonary hemorrhage A. Forced expiratory volume in 1 second (FEVj) D. Diffusing capacity of lung for carbon monoxide (Dlco) E. Functional residual capacity 34.2 Which of the following is a 50-year-old man with severe kyphoscoliosis most likely to have A. Enlarged overall lung volume C. Left rather than right ventricular failure E. Recurrent pulmonary infections 34.3 Which of the following is the best measure of airflow...

Clinical Approach

Transient ischemic attacks, often called mini-strokes, refer to the sudden onset of a focal neurologic deficit, with spontaneous resolution within 24 hours (usually within the first hour). Not all transient focal neurologic events actually represent ischemia, however. The differential diagnosis includes classic migraine, postictal paralysis, seizures, cerebral hemorrhage, or even slow-evolving intracranial processes such as subdural hematoma, abscess, or tumors, which can suddenly produce...

Objectives

Know the clinical and ECG features of pericarditis and be able to recognize a pericardial friction rub. 2. Know the causes of pericarditis and its treatment. 3. Know the diagnostic criteria for SLE. 4. Know the major complications of SLE and its treatment. In patients with chest pain, one of the primary diagnostic considerations is always myocardial ischemia or infarction. This is particularly true when the ECG is abnormal with changes that may represent myocardial injury, such as ST elevation....

Findings

Increased pressure in pericardial space due to effusion, impeding diastolic filling Pulsus paradoxicus, hypotension, elevated jugular venous distention, small quiet heart Low voltage diffusely, electrical alterans Inflammation and granulation tissue forms a thickened fibrotic adherent sac, commonly caused by radiation, viral infection, uremia Absent pulsus paradoxicus, Kussmaul sign, pericardial knock. Chronic and slow progressive weakness and exertional dyspnea Acute inflammation of the...

Approach To Suspected Anaphylaxis Definitions

Angioedema Swelling of the lips, periorbital region, face, hands, or feet. Anaphylactoid reactions Similar clinical picture to anaphylaxis but not caused by immunologic mechanisms. Anaphylaxis Syndrome with varied mechanisms, clinical presentations, and severity that is an acute life-threatening reaction resulting from an immunologic IgE-mediated mechanism. Common causes of anaphylaxis include drugs, hymcnoptera slings, radiographic contrast media (anaphylactoid), blood products, latex in...

Answers To Case 48 Anaphylaxis Drug Reactions

Summary A 25-year-old man develops facial edema and difficulty breathing minutes after receiving an injection of penicillin. He is tachypneic and tachycardie, with borderline hypotension. He is wheezing diffusely, his abdomen is nondistended with hyperactive bowel sounds, and his skin is warm with multiple raised urticarial lesions. Most likely diagnosis Anaphylaxis as a result of penicillin hypersensitivity. Next step Immediate administration of intramuscular epinephrine, along with...

Considerations

This 52-year-old man presents to the doctor's office with complaints of fatigue and dyspnea on exertion for the few months prior to the office visit. His physical examination is significant only for pallor. The serum hemoglobin level confirms anemia. The next step would be to characterize the anemia as microcytic, which would be consistent with iron deficiency, and confirmed with further testing for total iron-binding capacity (TIBC) and ferritin. The most likely source of blood loss in male...

Answers To Case 33 Syphilis

Summary A 23-year-old healthy man reluctantly requests evaluation of a non-tender lesion on his penis. He has never had any STDs and has an otherwise unremarkable medical history. He is afebrile, and his examination is notable for a shallow, mildly tender to palpation, clean ulcer without exudates or erythema on the glans penis. There are some small, tender, inguinal lymph nodes bilaterally. Most likely diagnosis Chancre of primary syphilis. Likely treatment Single intramuscular injection of...

References

Drug therapy The medical management of depression. N Engl J Med 2005 353 1819-1834. Reus VI. Mental disorders. In Kasper DL. Braunwald E. Fauci AS. et al., eds. Harrison's principles of internal medicine, 16th ed. New York McGraw-Hill, 2005 2547-2561. A 42-year-old Hispanic factory worker presents with complaints of dizziness. When asked to describe what dizzy means to her, she relates a feeling of movement, even though she is standing still. The first time it happened, she also felt a...

Info

NOTE Sl-serum iron TIBC-ioial iron-binding capacity. Reproduced, with permission, from Adamson JW. Iron deficiency and olher hypoproliferative anemias. In Braunwald E, Fauci AS. Kasper KL. el al. Harrison's principles of inlernal medicine. 16th ed. New York McGraw-Hill. 2005 590. NOTE Sl-serum iron TIBC-ioial iron-binding capacity. Reproduced, with permission, from Adamson JW. Iron deficiency and olher hypoproliferative anemias. In Braunwald E, Fauci AS. Kasper KL. el al. Harrison's principles...

L

Laboratory imaging assessment, 7-9 latent period, HIV infection, 83 latent tuberculosis. 293 late-stage syphilis, 309 LDL. See low-density lipoprotein left lower quadrant abdominal pain. 254 legionella, .163, 365 lesionts). 291-297 cavitary lung. 291-297 Ghon. 294 Jancway, 285 lytic bone. 339 leucopcnia. 220 leukemia, 259 leukocyte esterase. 485 leukocytosis. 165 Light-criteria. 417 likelihood ratio. 10 limb ischemia. 89-95 line sepsis. 259-265 lipohyalinosis. 431 low back pain. 233-239 answers...

Summary

There is no replacement for a careful history and physical examination. 2. There are four steps to the clinical approach to the patient making the diagnosis, assessing severity, treating based on severity, and following response. 3. Assessment of pretest probability and knowledge of test characteristics are essential in the application of test results to the clinical situation. 4. There are seven questions that help to bridge the gap between the textbook and the clinical arena.

Answers To Case 37 Pulmonary Embolism

Summary A 48-year-old woman is brought to the hospital for very acute onset of dyspnea and is found to be tachypneic, tachycardie, and hypoxemic. On physical examination, she has elevated jugular venous pressure and a loud pulmonic closure sound, perhaps signifying acutely elevated pulmonary pressures. All of these findings, especially the hypoxemia despite a clear chest radiograph, strongly suggest a pulmonary embolism (PE), most likely caused by a lower-extremity deep venous thrombosis (DVT),...

Causes Of Prerenal Acute Renal Failure

True volume depletion Gastrointestinal losses Renal losses (diuretics) Reduced effective arterial blood volume Nephrotic syndrome Systemic inflammatory response syndrome (SIRS) Medications ACE inhibitors NSAIDs Decreased cardiac output Congestive heart failure Pericardial tamponade causes of obstructive nephropathy are ureteral obstruction due to malignancy, or prostatic obstruction due to benign or malignant hypertrophy. The patient's symptoms depend on whether or not both kidneys are...

Approaching Reading

The clinical problem-oriented approach to reading is different from the classic systematic research of a disease. Patients rarely present with a clear diagnosis hence, the student must become skilled in applying the textbook information to the clinical setting. Furthermore, one retains more information when one reads with a purpose. In other words, the student should read with the goal of answering specific questions. There are several fundamental questions that facilitate clinical thinking....

F

See electrocardiogram echocardiograms. 4 edema. 129. 275. 438 peripheral. 41 pulmonary, 175 EDTA. See elhylenediamincletraacclic acid effusion complicated parapneumonic. 417 418 malignant pleural. 354 parapneumonic. 411-419 pericardial, 299-304 pleural. 411-119 transudative pleural. 416 Ehlers-Danlos syndrome. 76 Eikenetla corrodens, 286 electrocardiogram (ECG). 26-27. 27 electrolytes, 174-175. 399 elevated cardiac enzyme levels. 28 elevated jugular venous pressure. 301 elevated liver...

Ecg

The ECG often is critical in diagnosing acute MI and guiding therapy. A series of ECG changes reflect the evolution of the infarction (Figure 1-2). 1. The earliest changes are tall, positive, hyperacute T waves in the ischemic vascular territory. 2. This is followed by elevation of the ST segments (myocardial injury pattern). 3. Over hours to days. T-wave inversion frequently develops. 4. Finally, diminished R-wave amplitude or Q waves occur, representing significant myocardial necrosis and...

Laboratory Diagnosis

Laboratory values show hyperglycemia (usually > 250 mg dL), acidosis (pH < 7.3), anion gap (usually > 15 mmol L), and ketonemia. The most important laboratory parameters are the degree of acidosis, the anion gap, and the serum potassium level. Patients with a very low pH < 7.0 are severely acidotic and have a worse prognosis. The lower pH is a result of the higher concentration of ketoacids, which are estimated using the anion gap. The first step in evaluating any patient with metabolic...

V

Valvular damage in endocarditis. 286 VATS. See video-assisted thorascopic surgery VDRL. See venereal disease research laboratory venereal disease research laboratory (VDRL). 18-19.314 venous siasis. 345 ventilation perfusion (V Q), 344 ventricular aneurysm. 33 ventricular arrhythmias. 34 ventricular fibrillation (VF), 31 ventricular rate control. 49 ventricular septal rupture. 33 ventricular tachycardia (VT> . 31 Verapamil. 52 vertigo. 532. 534. See also benign positional vertigo central. 532...

Usethe Learning System Provento Increase Shelf Exam Scores

You need exposure to cases to pass the internal medicine shelf exam and this resource provides exactly that. Case Files Internal Medicine presents 60 clinical cases illustrating essential concepts in internal medicine. Perfect for the i clerkship and the USMLE Step 2, each case includes an extended discussion, definitions of key terms, clinical pearls, and USMLE-style review questions.This interactive learning system helps you to learn instead of just memorize. Superior to other case file...

Approach To Pleural Effusion Definitions

Exudate Effusion caused by inflammatory or malignant causes, usually with high protein or high lactate dehydrogenase (LDH) levels. Pleural effusion Accumulation of fluid in the pleural space. Transudate Effusion caused by alteration of oncotic forces, usually with low protein and low LDH levels. Diagnostic thoracentesis should be considered for every patient who presents with a chest radiograph with evidence of pleural effusion. Possibly the only exception to this rule is if the patient is...

Diagnosis

The most common symptom associated with chronic arterial insufficiency caused by PAD is intermittent claudication, characterized by pain. ache, a sense of fatigue, or other discomfort that occurs in one or both legs during exercise, such as walking, and is relieved with rest. It is ischemic pain and occurs distal to the site of the arterial stenosis, most commonly in the calves. The symptoms often are progressive and may severely limit a patient's activities and reduce the patient's functional...

Case

A 32-year-old man infected with human immunodeficiency virus (HIV), whose last CD4 count is unknown, presents to the emergency room with a fever of 102.5 F. He was diagnosed with HIV infection approximately 3 years ago when he presented to his doctor with oral thrush. He was offered highly active antiretroviral therapy (HAART) and stayed on this regimen until approximately 10 months ago, when he lost his job and insurance and could no longer pay for the drugs and discontinued all treatment. He...

Diagnostic Criteria For Endocarditis

Isolation of typical organisms (viridans streptococci, Staphylococcus aureus, enterococci, Streptococcus bovis, or one of the HACEK organisms) from two separate blood cultures, or persistently positive blood cultures with other organisms 2. Evidence of endocardial involvement either echocardiographic evidence of endocarditis, e.g., oscillating intracardiac mass, or new valvular regurgitation 1. Predisposing valvular lesion or intravenous drug use 2. Fever > I(K).4 F (38.0 C) 3. Vascular...

Iron Deficiency

Although anemia may be caused by disorders of bone marrow production, red cell maturation, or increased destruction, iron deficiency is the most common cause of anemia in the United States, affecting all ages and both genders. Iron is essential to the synthesis of hemoglobin. The normal daily intake of elemental iron is approximately 15 mg, of which only 1-2 mg is absorbed. The daily iron losses are about the same, but menstruation adds approximately 30 mg of iron lost each month. The primary...

Eugene Ctoy Md

Academic Chair and Program Director The Methodist Hospital-Houston Obstetrics and Assistant Course Director Clerkship Director, Ob Gyn Junior Clerkship University ofTexas Medical School at Houston Houston, Texas Assistant Professor of Medicine Department of General Internal Medicine MD Anderson Cancer Center Houston.Texas Associate Professor, Division of General Medicine Department of Internal Medicine University ofTexas Medical School at Houston Houston.Texas New York...

Hip Oa

Joint space narrowing on x-rays Pharmacotherapy early in the course of the disease consists primarily of acetaminophen, the mainstay of therapy. It is well tolerated and as effective as nonsteroidal antiinflammatory drugs (NSAIDs both nonprescription and prescription strength). The nutraceutical agents glucosamine and chondroitin are as effective as the NSAIDs, but their onset of action is a bit slower. NSAIDs inhibit the enzyme cyclooxygenase (COX) in the prostaglandin catabolism pathway and...

Answer To Case 8 Limb Ischemia Peripheral Vascular Disease

Summary A 58-year-old man presents to the emergency room with severe pain and numbness of his left foot. He has angina and a carotid bruit suggesting systemic atherosclerotic disease. He previously had symptoms of bilateral calf claudication but now has sudden onset of pain, pallor, and pulselessness in the left foot. Most likely diagnosis Acute limb ischemia, either thrombotic arterial occlusion or embolism from a distant source. Next step Angiogram of the lower extremity.

Approach To Clinical Problem Solving

The next step is to try to move from subjective complaints or nonspecific symptoms to focus on objective abnormalities in an effort to conceptualize the patient's objective problem with the greatest specificity one can achieve. For example, a patient may come to the physician complaining of pedal edema, a relatively common and nonspecific finding. Laboratory testing may reveal that the patient has renal failure, a more specific cause of the many causes of edema. Examination of the urine may...

Approach To Headaches

Headache is one of the most common complaints of patients in the western world. It periodically afflicts 90 of adults, and almost 25 have recurrent severe headaches. As with many common symptoms, a broad range of conditions, from trivial to life-threatening, might be responsible. The majority of patients presenting with headache have tension-type, migraine, or cluster however, fewer than one in 20 have significant underlying pathology. Because headache symptoms usually are accompanied by a...

Unstable Angina Classification

New or worsened angina not at rest II. Angina at rest, last occurred more than 48 hours ago III. Angina at rest within last 48 hours A. Secondary angina -noncoronary precipitant (e.g., anemia, thyrotoxicosis, infection) B. Primary angina in the absence of an extracardiac condition C. Postinfarction angina within 2 weeks after a myocardial infarction, with those in class IIIC having the worst prognosis. Source Braunwald E. Unstable angina A classification. Circulation 1989 80 410-414. (e.g...

Symptoms Of Major Depression

Each letter stands for a criterion (except for depressed mood) used in diagnosing a major depressive episode. Five or more of the following criteria are needed for at least 2 weeks S sleep changes I (decreased) interest G (excessive) guilt E (decreased) energy C (decreased) concentration A appetite changes P psychomotor agitation or retardation S suicidal ideation APPROACH TO DEPRESSIVE DISORDER Definitions Atypical depression Depressed mood with increased sleeping, increased...

Common Causes Of Acute Pericarditis

Idiopathic pericarditis specific diagnosis unidentified, presumably either viral or autoimmune and requires no specific management Infectious viral, bacterial, tuberculous, parasitic Vasculitis autoimmune diseases, postradiation therapy Hypersensitivity immunologic reactions, e.g Dressier syndrome Diseases of contiguous structures, e.g during transmural myocardial infarction Metabolic disease, e.g uremia. Gaucher disease Trauma penetrating or nonpenetrating chest injury Neoplasms usually...

Causes Of Intrinsic Acute Renal Failure

Acute tubular necrosis Nephrotoxic agents Ischemic Hypotension Vascular catastrophe Glomerulonephritis Postinfectious Vasculitis Immune complex diseases (lupus. MPGN mesangioproliferative glomerulonephritis cryoglobulinemia) Cholesterol emboli syndrome Hemolytic uremic syndrome thrombotic thrombocytopenic purpura Medications (cephalosporins, methicillin, rifampin) Infection (pyelonephritis, HIV) Medications (cephalosporins, methicillin, rifampin) Infection (pyelonephritis, HIV)

Answers To Case 41 Painless Jaundice Pancreatic Cancer

Summary A 57-year-old man presents with pruritus, weight loss, and light-colored stools. He is found to be jaundiced with markedly elevated alkaline phosphatase level and conjugated hyperbilirubinemia. All of these findings point toward cholestasis. The light-colored, or acholic, stools suggest the cholestasis is most likely caused by biliary obstruction. The absence of abdominal pain makes gallstone disease less likely. Most likely diagnosis Biliary obstruction, most likely caused by...

Chd Risk Factors

Hypertension (elevated blood pressure when seen, or patient on antihypertensives) Low HDL cholesterol (< 40 mg dL) Family history of premature coronary artery disease (in men < 55 years or in women < 65 years) Age of the patient (men > 45 years, women > 55 years) (> 20 ), intermediate risk (10-20 ), or low risk (< 10 ). Those in the intermediate-risk category should have an LDL goal < 130 mg dL, whereas the lowest-risk patients have an LDL goal < 160 mg dL. One should exclude...

S

Secondary adrenal insufficiency. 371 secretion of antidiuretic hormone. 294 selective serotonin reuptake inhibitor (SSRI). 448. 524 semicircular canals. 534 septic shock. 487 sputum copious, production. 353 early morning. 295 rust-colored. 362 serial blood cultures. 285 serum ferritin. 244, 246 serum ketone. 398 serum sickncss. 440 severe esophagitis. 465 sexual dysfunction. 527 shigella. 162 S1ADH. See syndrome of inappropriate antidiuretic hormone sccrction sickle cell anemia. 267-271 answers...

Clinical Pearl

When the pretest probability of a disease is high based on risk factors, even with a negative initial test, more definitive testing may be indicated. What Are the Complications to This Process A clinician must understand the complications of a disease so that one may monitor the patient. Sometimes the student has to make the diagnosis from clinical clues and then apply his her knowledge of the sequelae of the pathological process. For example, the student should know that chronic hypertension...

Approach To Suspected Diabetes Mellitus Definitions

Type I diabetes Caused by what is believed to be an autoimmune destruction of the pancreatic beta cells and complete loss of endogenous insulin production. The presentation of this type of diabetes usually is acute, with hyperglycemia and metabolic acidosis. These patients are dependent upon exogenous insulin delivery. Type 2 diabetes Heterogenous syndrome of insulin resistance caused by genetic factors and or obesity and relative insulin deficiency. Oral medications to enhance endogenous...

Approach To Suspected Lyme Disease

The evaluation of the patient who presents with fever and a rash is a very common problem that often frustrates and confuses beginning clinicians, partly because of their unfamiliarity with many typical rash patterns, and partly because the rash may be an incidental nonspecific finding (as in miliaria or heat rash), may be a sign of serious, even fatal illness (as in the purpuric rash of meningococcemia), or may be the pathognomonic finding that yields the diagnosis, as in the case of the...

Approach To Painless Jaundice Definitions

Cholestasis Deficient bile flow that can result from intrahepatic disease or extrahepatic obstruction. Conjugated bilirubin (direct-reacting bilirubin) Bilirubin that has entered the liver and been enzymatically bound to glucuronic acid forming bilirubin monoglucuronide or diglucuronide. Jaundice or icterus Yellowing of the skin or whites of the eyes, indicating hyperbilirubinemia. Unconjugated bilirubin (indirect-reacting bilirubin) Bilirubin that has not been enzymatically bound to glucuronic...

Clinical Pearls For Diagnosis Of Exclusion

Fistulas are common with Crohn disease because of its transmural nature but are uncommon in ulcerative colitis. 16.2 C. Pancolitis has the highest risk of malignancy in ulcerative colitis. 16.3 C. With toxic megacolon, antibiotics and surgical intervention are often necessary. 16.4 B. Irritable bowel syndrome is characterized by intermittent diarrhea and crampy abdominal pain, but no weight loss or abnormal blood in the stool. It is a diagnosis of exclusion once other conditions, such...

Epidemiology

Sickle cell anemia is the most common autosomal recessive disorder and the most common cause of hemolytic anemia in African Americans. Approximately 8 of African Americans carry the gene (i.e., sickle cell trait), with one in 625 affected by the disease. Complications of Sickle Cell Disease Acute painful episodes, also known as pain crisis, are a consequence of microvascular occlusion of bones by sickled cells. The most common sites are the long bones of the arms, legs, vertebral column, and...

Answers To Case 43 Diabetic Ketoacidosis

Summary A young woman presents with unintentional weight loss, nocturia, and polyuria, with hyperglycemia that likely represents new-onset diabetes mellitus. She is hypovolemic as a result of osmotic diuresis and has an anion gap metabolic acidosis, which is primarily caused by ketoacids. Her mental status and abdominal pain probably are manifestations of the metabolic acidosis and hyperosmolarity. Most likely diagnosis Diabetic ketoacidosis (DKA). Next step Aggressive hydration to improve her...

Alcohol Withdrawal

Tremulousness Earliest symptom occurring within 6 hours of abstinence, caused by CNS and sympathetic hyperactivity, often referred to as the shakes or jitters, and can occur even when patients still have a significant blood alcohol level. In addition to the typical 6- to 8-Hz tremor, which can be violent or subtle, insomnia, anxiety, gastrointestinal upset, diaphoresis, and palpitations can occur. Tremor typically diminishes over 48-72 hours, but anxiety, easy startling, and other symptoms can...

Approach To Suspected Endocarditis

Infectious endocarditis refers to a microbial process of the endocardium, usually involving the heart valves. The clinical presentation depends upon the valves involved (left-sided versus right-sided), as well as the virulence of the organism. Highly virulent species, such as Staphylococcus aureus, produce acute infection, and less virulent organisms, such as the viridans group of streptococci, tend to produce a more subacute illness, which may evolve over weeks. Fever is present in 95 of all...

Cost

Supplements patient's own insulin production Must check blood glucose frequently to monitor therapy and prevent complications Augments patient's own insulin production, works at the pancreatic beta cells Can cause hypoglycemia can accumulate in renal insufficiency and cause prolonged hypoglycemia. Best for young patients with fasting plasma glucose < 300 mg dL gluconeogenesis in the liver decreases insulin resistance In patients with renal insufficiency or liver dysfunction may cause lactic...

Bleeding

A careful history is the most effective way to determine the presence and significance of a bleeding disorder. Abnormal hemostasis may result from liver disease, uremia, malignancy, or systemic lupus erythematous. The history should include medications, including over-the-counter products (aspirin), family history of abnormal bleeding, epistaxis, menorrhagia, excessive prolonged bleeding from minor cuts, bruising, prolonged or profuse bleeding after dental extraction, excessive bleeding after...

Criteria For Diagnosis Of Diabetes Mellitus

Symptoms of diabetes plus casual glucose concentration > 200 mg dL (11.1 mmol L). Casual is defined as any time of day without regard to time since last meal. The classic symptoms of diabetes include polyuria, polydispsia, and unexplained weight loss. 2. FPG > 126 mg dL (7.0 mmol L). Fasting is defined as no caloric intake for at least 8 hours. 3. 2hPG > 200 mg dL during an OGTT. The test should be performed as described by WHO, using a glucose load containing the equivalent of 75-g...

Approach To Acute Renal Failure Definitions

Acute renal failure (ARF) Abrupt decline in glomerular filtration rate (GFR). True GFR is difficult to measure, so we rely on increases in serum creatinine levels to indicate a fall in GFR. Because creatinine is both filtered and secreted by the kidneys, changes in serum creatinine concentrations always lag behind and underestimate the decline in the GFR. In other words, by the time the serum creatinine level rises, the GFR has already fallen significantly. Anuria Less than 50 mL of urine...

Associated Conditions

Intravascular catheter, intravenous drug use (tricuspid valve endocarditis) 30-35 of early prosthetic valve infection Previous genitourinary tract disease or instrumentation Elderly patients, often with underlying GI mucosal lesion, e.g., adenoma or malignancy Intravascular catheters, intravenous drug use actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, Kingella kingae). The clinical features, blood cultures, and echocardiography are used to diagnose cases of endocarditis...

Answers To Case 4 Peptic Ulcer Disease

Summary A 37-year-old man presents with complaints of chronic and recurrent upper abdominal pain with characteristics suggestive of duodenal ulcer the pain is burning, occurs when the stomach is empty, and is relieved within minutes by food or antacids. He does not have evidence of gastrointestinal bleeding or anemia. He does not take nonsteroidal antiinflammatory drugs, which might cause ulcer formation, but he does have serologic evidence of H. pylori infection. Most likely diagnosis Peptic...

Treatment

Gemeinsames Schema Haushalt

Treatment options can be categorized in terms of primary and secondary therapy based on different management goals. Primary therapy consists of clot dissolution or thrombolysis or removal of clot by surgical embolectomy and usually is reserved for patients with a high risk for adverse outcomes if the clot remains, that is. those with right-heart failure or hypotension. When right-heart function remains normal, patients typically have good outcomes with anticoagulation as secondary therapy....

Medical Causes Of Delirium

Discrete CNS lesion present Head injury stroke or intracranial bleed Infection meningitis, meningoencephalitis, brain abscess Mass lesion hematoma, tumor Seizure, postictal No discrete CNS lesion Metabolic encephalopathy Anoxia any cause, heart or respiratory failure, pulmonary embolus, sleep apnea, etc. Hepatic encephalopathy Uremic encephalopathy Hypo- hyperglycemia Hyponatremia hypercalcemia Hypo- hyperthermia Drug withdrawal, especially alcohol and benzodiazepines, but also demerol and many...

Adverse Effects

Volume overload, electrolyte disturbances Hypophosphatemia, hypomag-nesemia, hypocalcemia, fever Efficacy short-lived (tachyphylaxis) Glucocorticoids (effective in cancer-induced hypercalcemia) Hyperglycemia, osteoporosis, immune suppression Dialysis (renal Acute (hours) Volume shifts, electrolyte dis- insufficiency) orders, complicated procedure Dialysis (renal Acute (hours) Volume shifts, electrolyte dis- insufficiency) orders, complicated procedure intoxication with vitamin A, vitamin D. or...

Atn

Isosthenuric with muddy brown granular casts Moderate to severe proteinuria with red blood cells and red blood cell Mild to moderate proteinuria with red and white blood cells and white blood cell casts < 20 mEq L (early) > 20 mEq L (later) urinalysis usually reveals a high specific gravity and normal microscopic findings. Individuals with postrenal failure typically arc unable to concentrate the urine, so the urine osmolality is equal to the serum osmolality (isosthenuria) and the specific...

Approach To Peripheral Vascular Disease Definitions

Ankle-brachial index (ABI) Ratio of ankle to brachial systolic blood pressure determined using Doppler ultrasound flow. Claudication syndrome Calf pain that increases with walking or leg exertion in a predictable manner and resolves with rest. Although atherosclerosis is a systemic disease, clinicians often focus on the coronary circulation and are less attentive to the extremities. Yet atherosclerotic peripheral arterial disease (PAD) is estimated to affect up to 16 of Americans 55 years and...

Approach To Syncope

Syncope is a transient loss of consciousness and postural tone with subsequent spontaneous recovery. It is a very common phenomenon, resulting in 5-10 of emergency room visits and resulting hospitalization. The causes are varied, but they all result in transiently diminished cerebral perfusion leading to loss of consciousness. The prognosis is quite varied, ranging from a benign episode in an otherwise young, healthy person with a clear precipitating event, such as emotional stress, to a more...

Can Haemoptysis Cause Asphyxiation By Filling Up Alveolar Airs Spaces

Horner syndrome Symptoms are ptosis, loss of pupillary dilation (miosis), and loss of sweating on the same side of the face (anhydrosis) caused by compression of the superior cervical ganglion. Superior vena cava syndrome Obstruction of venous drainage leads to dilation of collateral veins of the upper part of the chest and neck, edema of the face, neck and upper part of the torso, shortness of breath, and central nervous system (CNS) symptoms, such as confusion, headache, and visual problems....

The Nephritic Syndrome

The presentation of acute renal failure with associated hypertension, hematuria, and edema is consistent with acute GN. Acute renal failure, as manifested by a decrease in urine output and azotemia, results from impaired urine production and ineffective filtration of nitrogenous waste by the glomerulus, respectively. The glomerular apparatus (endothelial and epithelial components) is responsible for the ultrafiltration of blood in the kidney and the initial formation of what will later become...

Approach To Suspected Diabetic Ketoacidosis

DKA is a clinical syndrome that results when the triad of anion gap metabolic acidosis, hyperglycemia, and ketosis is present and is caused by a significant insulin deficiency. It is a medical emergency, with an overall mortality rate < 5 if patients receive prompt and appropriate medical treatment. The majority of episodes are preventable, and many of the deaths also are preventable with proper attention to detail during management. In the normal physiologic state, there is a fine balance...

Approach To Hyperlipidemia

Atherosclerotic coronary artery disease is the leading cause of death of both men and women in the United States. Because of the association of hypercholesterolemia and development of atherosclerotic heart disease, most authorities recommend routine screening of average risk individuals at least every 5 years. Clinical laboratories usually measure total cholesterol, HDL, and triglycerides. The LDL cholesterol may be calculated by using the formula LDL Total cholesterol - HDL - (Triglycerides 5)...

Approach To Dementia

Dementia Impairment of memory and at least one other cognitive function (e.g., language, visuospatial orientation, judgment) without alteration in consciousness, representing a decline from previous level of ability and interfering with daily functioning and independent living. Alzheimer disease Leading cause of dementia, accounting for half of the cases involving elderly individuals, correlating to diffuse cortical atrophy and hippocampal atrophy with ventricular enlargement. The pathologic...

Answers To Case 7 HIV and Pneumocystis Carinii Pneumonia

Summary A 32-year-old man with known HIV infection but unknown CD4 count presents with subacute onset of fever, dry cough, and gradually worsening dyspnea. He is not undergoing any antiretroviral therapy or taking prophylactic medications. Diffuse bilateral pulmonary infiltrate is seen on chest x-ray. and he is tachypneic and hypoxemic. The presence of oral thrush suggests that he is immunosuppressed. His leukocyte count is decreased, and his LDH level is elevated. Most likely diagnosis...

Red Flags For Secondary Headache Disorders

Fundamental change or progression in headache pattern First severe and or worst headache Abrupt-onset attacks, including those awakening one from sleep Abnormal physical examination findings (general or neurologic) Neurologic symptoms lasting > 1 hour New headache in individuals aged < 5 years or > 50 years New headache in patients with cancer, immunosuppression, pregnancy Headache associated with alteration in or loss of consciousness Headache triggered by exertion, sexual activity, or...

Approach To Suspected Mi

Acute coronary syndrome Spectrum of acute cardiac ischemia ranging from unstable angina (ischemic pain at rest or at lower threshold of exertion or new onset of chest pain) to acute MI (death of cardiac tissue), usually precipitated by thrombus formation in a coronary artery with an atherosclerotic plaque. Acute myocardial infarction Death of myocardial tissue because of inadequate blood flow. Non-ST elevation myocardial infarction (NSTEMI) MI. but without ST elevation as defined below. May...

Monitoring

HMG-CoA reductase inhibitors (statins) Lower LDL 25-55 Lower TG 10-25 Raise HDL 5-10 Lower TG 25-35 Lower LDL 15-25 Raise HDL 15-30 Bile acid resins (e.g cholestyramine) Fibric acid derivatives (e.g gemfibrozil) LFT liver function test TG triglycerides. From Rader DJ. Hobbs HH. Disorders of lipoprotein metabolism. In Braunwald E, Fauci AS. Kasper KL. ct al. eds. Harrison's principles of internal medicine, 16th ed. New York McGraw-Hill. 2005 2296. LFT liver function test TG triglycerides. From...

Answers To Case 25 Iron Deficiency Anemia

Summary A healthy 52-year-old man complains of a 4- to 5-month history of increasing exercise intolerance, but he denies orthopnea, PND. edema, or other signs of heart failure. The patient uses an nonsteroidal antiinflammatory drug (NSAID) regularly. He has not had any overt gastrointestinal (GI) blood loss. On examination, he weighs 205 lb, and he has slight pallor of the conjunctiva, skin, and palms. He is anemic, with a hemoglobin level of 8.2 g dL. Most likely diagnosis Iron-deficiency...

Classification Of Glomerulonephritis Based On Clinical Presentation

Primary renal disorders (based on histopathology) Membranoproliferative glomerulonephritis (MPGN, types I and II) Mesangioproliferative glomerulonephritis (MSGN) Crescentic glomerulonephritis Immune deposit (anti-GBM) Pauci-immune (ANCA) Fibrillary glomerulonephritis Proliferative glomerulonephritis (IgA nephropathy) Secondary renal disorders (based on clinical presentation) Lupus nephritis Postinfectious glomerulonephritis (poststreptococcal GN) Hepatitis C hepatitis B-related...

Etiologies Of Rhabdomyolysis

Drug abuse (cocaine, amphetamines, LSD, heroin, phencyclidine) Medications (diuretics, narcotics, theophylline, corticosteroids, benzodiazepines, phenothiazides, tricyclic antidepressants) Trauma High temperatures Heat stroke Strenuous exercise Seizures Toxin ingestion Infection renal failure and possible multiorgan failure. One key finding is urine dipstick showing blood but urine microscopy not identifying red blood cells. Serum markers, such as creatinine kinase, then can be measured. The...

Approach To Colitis

The differential diagnosis for colitis includes ischemic colitis, infectious colitis (C. difficile. E. coli, Salmonella, Shigella, Campylobacter), radiation colitis, and IBD (Crohn disease versus ulcerative colitis). Mesenteric ischemia usually is encountered in people older than 50 years with known atherosclerotic vascular disease or other cause of hypoperfusion. The pain usually is acute in onset following a meal and not associated with fevers. With an infectious etiology, patients often have...

Pleural Fluid Appearance

Clear yellow Transudative, e.g., secondary to CHF. cirrhosis, nephrotic syndrome Frank pus Infectious process, empyema Bloody If the hematocrit of the pleural fluid is < 1 Blood caused by traumatic tap 1-20 Cancer, pulmonary embolus, tuberculosis > 50 Hemothorax, most commonly secondary to trauma but also seen in malignancy and pulmonary embolism Milky, turbid Chylothorax triglycerides > 110 mg dL resulting from disruption of thoracic duct, cholesterol effusion To appreciate the...

Ranson Critieria For Severity Of Pancreatitis

Age > 55 years WBC > 16.000 mm' Serum glucose > 200 Serum lactate dehydrogenase (LDH) > 350 IU L AST > 250 IU L Within 48 hours of admission Hematocrit drop > 10 points Blood urea nitrogen (BUN) rise > 5 mg dL after intravenous hydration Estimated fluid sequestration of > 6 L Source Ranson JH. Etiological and prognostic factors in human acute pancreatitis A review. Am J Gastroenterol 1982 77 633. processes, but in the United States, alcohol use is the most common cause, and...

Nyha Functional Classification

Class I No limitation during ordinary physical activity. Class II Slight limitation of physical activity. Develops fatigue or dyspnea with moderate exertion. Class III Marked limitation of physical activity. Even light activity produces symptoms. Class IV Symptoms at rest. Any activity causes worsening. low oxygen consumption during exercise have an annual mortality rate of 20 in class IV. the rate is 60 annually. Patients with a low ejection fraction (LVEF < 20 ) also have very high...

Secondary Causes Of Hypertension

Parenchymal (glomerulonephritis, polycystic renal disease, diabetic nephropathy) Renovascular Primary aldosteronism Cushing syndrome Pheochromocytoma Hyperthyroidism Growth homione excess (acromegaly) Oral contraceptives Increased intravascular volume (posttransfusion) Hypercalcemia Medications (sympathomimetics, glucocorticoids) smoking, dyslipidemia, diabetes mellitus, obesity, kidney disease, and a family history of premature cardiovascular disease. Target organ damage of hypertension...

Basic Tests For Initial Evaluation Of Hypertension

Urine for protein, blood, glucose, and microscopic examination Hemoglobin or hematocrit leukocyte count Serum creatinine or blood urea nitrogen Total. HDL. and LDL cholesterol triglycerides Electrocardiogram Consider thyroid-stimulating hormone abdomen for enlarged kidneys, masses, or an enlarged abdominal aorta, evaluation of the lower extremities for edema and perfusion, and a neurologic examination should be standard. Some initial laboratory testing is also indicated (Table 9-3). Counseling...

Pathophysiology

When venous thrombi dislodge from their site of formation, they may embolize to the pulmonary arteries causing PE. The deep proximal lower-extremity veins are the most common site of clot formation resulting in PE. although thromboses in pelvic, calf, and upper-extremity veins may also embolize. Obstruction to the pulmonary artery causes platelets to release vasoactive agents such as serotonin, thereby elevating pulmonary vascular resistance. The resulting increase in alveolar dead space and...

Hypercalcemia Harrison

Hypercalcemia And Diagnostic Algorithm

Bolser DC, et al. Diagnosis and management of cough executive summary ACCP evidence-based clinical practice guidelines. Chest 2 X 6 129 I Suppl IS-23S. Irwin RS, Madison JM. The diagnosis and treatment of cough. N Engl J Med 2000 343 1715-1721. Morice AH. Kastelik JA. Chronic cough in adults. Thorax 2003 58 901-907. Williams SG. Schmidt DK. Redd SC. et al. National Asthma Education and Prevention Program. Key clinical activities for quality asthma care. Recommendations of...

Approach To Suspected Cardiac Tamponade

Cardiac tamponade refers to increased pressure within the pericardial space caused by an accumulating effusion, which compresses the heart and impedes diastolic filling. Because the heart can only pump out during systole what it receives during diastole, severe restrictions of diastolic filling lead to a marked decrease in cardiac output, which can cause cardiovascular collapse and death. If pericardial fluid accumulates slowly, the sac may dilate and hold up to 2000 mL producing amazing...

Test

ANA, anti-LKM liver kidney microsome High transferrin saturation gt 50 , high ferritin HBeAg hepatitis B e antigen HBsAg hepatitis B surface antigen. HBeAg hepatitis B e antigen HBsAg hepatitis B surface antigen. in the 10 years following infection. Within 20 years, 30 of those will develop cirrhosis, and over 30 years, 30 of those with cirrhosis may develop hepatocellular carcinoma. Therapy is directed toward reducing the viral load to prevent the sequelae of end-stage cirrhosis, liver...

High Anion Gap Metabolic Acidosis

Renal failure acute or chronic Reproduced with permission from DuBoseTD. Acidosis and alkalosis. In Braunwald E. Fauci AS, Kasper KL. et al, eds. Harrison's principles of internal medicine. 16th ed. New York McGraw-Hill, 2005 265. alcoholism discussed later . The ingested toxins may be organic acids themselves, such as salicylic acid, or have acidic metabolites, such as formic acid from methanol. Renal failure leads to an inability to excrete organic acids as well as inorganic acids such as...

Common Causes Of Hematuria

Intrarenal Hematuria Kidney trauma Renal stones and crystals Glomerulonephritis Infection pyelonephritis Neoplasia renal cell carcinoma Vascular injury vasculitis, renal thrombosis Extrarenal Hematuria Trauma e.g., Foley placement Infections urethritis, prostatitis, cystitis Nephrolithiasis ureteral stones Neoplasia prostate, bladder imaging studies often are necessary, and considering the potential clinical implications, the etiology of hematuria should be pursued in all cases of hematuria....

Cases

A 58-year-old man presents to the emergency room complaining of severe pain in his left foot that woke him from sleep. He has a history of chronic stable angina, hypercholesterolemia, and hypertension, for which he takes aspirin, atenolol, and simvastatin. He has experienced pain in both calves and feet with walking for several years, and the pain has gradually progressed so that he can now only walk 100 feet before he has to stop because of pain. He occasionally has experienced mild pain in...

Complication Characteristics Treatment

Abscess Suspected in patients with Conservative management for a tender mass on small pericolic abscesses. CT- examination. persistent guided percutaneous drainage or fever and leukocytosis in surgical drainage for other spite of adequate therapy, abscesses depending 011 the size, or a suggestive finding on content, location, and peritoneal imaging studies. contamination. Fistulas Majority is colovesical with Single-stage surgery with fistula male predominance be- closure and primary...

Prothrombin Time

Normal to 5 mg dL 85 due to indirect fractions No bilirubinuria Acute hepatocellular necrosis viral and drug hepatitis, hepatotoxins. acute heart failure Both fractions may be elevated. Peak usually follows aminotransferases Bilirubinuria Elevated, often gt 500 IU L ALT gt AST Normal to lt 3 times normal elevation Usually normal gt 5X above control and not corrected by parenteral vitamin K, suggests poor prognosis Both fractions may be elevated Bilirubinuria Normal to lt 3 times normal...

Approach To Hyperthyroidism Definitions

Hyperthyroidism Hypermetabolic condition that results from the effect of excessive amounts of thyroid hormones produced by the thyroid gland itself. Because almost all cases of thyrotoxicosis are caused by thyroid overproduction, these terms are often used synonymously. Thyrotoxicosis Usually used as a general term for biochemical and physiologic manifestations of excessive levels of thyroid hormones from any source, for example, exogenous ingestion. Hyperthyroidism affects numerous body...

Fundus Reveals Dot Hemorrhages And Hard Exudates Related To

Inflammatory bowel disease. Medical therapy of specific clinical presentations. Gastroenterol Clin North Am 2002 341 147-166. Kornbluth A. Sachar DB. Ulcerative colitis practice guidelines in adults update . Am J Gastroenterol 2004 99 1371-1385. Podolsky DK. Medical progress Inflammatory bowel disease. N Engl J Med 2002 342 7. Stenson WF. Inflammatory bowel disease. In Goldman L, Bennett JC, eds. Cecil's textbook of medicine. 21st ed. WB Saunders. Philadelphia PA....

Answers To Case 17 Acute Renal Failure

Summary A 54-year-old diabetic male is receiving medical therapy consisting of oral aspirin, beta-blockers. ACE inhibitor, and intravenous nitroglycerin for treatment of his angina and hypertension. He undergoes coronary angiography, which reveals no significant stenosis. He is normotensive. His funduscopic examination shows dot hemorrhages and hard exudates, evidence of diabetic retinopathy. In this setting, the baseline elevated creatinine level on admission likely represents diabetic...

Answers To Case 40 Adrenal Insufficiency

Summary A 58-year-old woman presents with orthostatic hypotension, intermittent chronic abdominal pain, and constitutional symptoms such as fatigue and unintentional weight loss. She also has hyponatremia, hyperkalemia, acidosis. and hypoglycemia. All of this patient's clinical features are consistent with acute adrenal insufficiency. Although the most common cause of adrenal insufficiency is idiopathic autoimmune destruction, in her case, it may be due to adrenal metastases from breast cancer....

Blood Pressure Of 108

Pulmonary tuberculosis diagnosis and treatment. BMJ 2006 332 1194-197. Jasmer RM. Nahid P, Hopewell PC. Latent tuberculosis infection. N Engl J Med 2002 347 1860-1866. Raviglione MC. O'Brian R. Tuberculosis. In Kasper DL, Braunwald E, Fauci AS, et al, eds. Harrison's principles of internal medicine, 16th ed. New York McGraw-Hill, 2005 953-966. Small PM, Fujiwara PI. Management of tuberculosis in the United States. N Engl J Med 2001 345 189-200. A 42-year-old man...

Approach To Aortic Aneurysm And Dissection Definitions

Abdominal aortic aneurysm AAA Defined as a pathologic dilation to more than 1.5 times the normal diameter of the aorta. Aneurysms can occur anywhere in the thoracic or abdominal aorta, but the large majority occur in the abdomen, below the renal arteries. Aortic dissection dissecting hematoma Tear or ulceration of the aortic intima that allows pulsatile aortic flow to dissect longitudinally along elastic planes of the media, creating a false lumen or channel for blood flow. Sometimes referred...

Clinical Features

The clinical presentation depends on the relative deficiency of glucocorticoids and mineralocorticoids, ACTH excess, and other associated disorders. Acute adrenal insufficiency, or Addisonian crisis, may present with weakness, nausea, vomiting, abdominal pain, fever, hypotension, and tachycardia. Laboratory findings may include hyponatremia, hyperkalemia, metabolic acidosis, azotemia as a consequence of aldosterone deficiency, and hypoglycemia and eosinophilia as a consequence of Cortisol...